Healthcare Provider Details

I. General information

NPI: 1588406177
Provider Name (Legal Business Name): NEUROEVOLVE INTEGRATIVE HEALTH, A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10085 CARROLL CANYON RD STE 200H
SAN DIEGO CA
92131-1100
US

IV. Provider business mailing address

10085 CARROLL CANYON RD STE 200H
SAN DIEGO CA
92131-1100
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-3463
  • Fax:
Mailing address:
  • Phone: 858-208-3463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMANTHA D WILSON
Title or Position: CFO
Credential: PSYD, LCSW
Phone: 760-616-9311